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0301-385 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 3475515 AB WC AiG6,TM�JP t .'iSignature! :gp Date of Contractor � OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: (' )., I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). () I am exempt under Section B&P.C. for this reason Date' Signature of Owner- WORKER'S wner WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. .41) 1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are:. Carrier STATESAID Policy No. 1 044,02.ODIMB , (This section need not be completed if the permit valuation'is for $100.00 or less). O I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject -to the workers' compensation provisions of Section 3700Fof the Labor Code; I shall forthwith comply withprovisions.l +� Date: thos wneY Applicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of. Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work. is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for I spectioneodrpose '� ,Signature (Owner/Agent)" Date ; �. 1d WATION 2,000..,00 T PEW= F.K.Eff9hMARY PLLIMBINO F'VP, 8EWER 101.000419-000 $30.00 Ilo JAN 2 i 2003 CITY OF LA QUINTA LE33 PR:9nPAM 1911`1 ". WAL PERM IfEF.6 DM NOW RECEIPT DATE BY �f ID FINALE D C'� I INSPECTSjX, 2.,ifit0.0 3 $30,00 5030.: ` "' LDING PERMIT PERMIT" DATE V�_UATION LOT TRACT pq ppyy y�aq �3ipi llfe� :a+'-d'y �y p�ry�lVyf 4YtlrDV37l7.vJOi , J:. � .�:e JOB SITE APN ADDRESS OWNER V CONTRACTOR(DESIGNER/EN INEER - MTICKMMU, M, .1 STAR C;ClNTIS` 'f 1=1 100 51.-24AAYES AEIEJO 34*730DA%E'iNA DRIVE LA QV RK Ck nLs,3 IT�.JRAL I.41TY CA ya.l u g C160)321-0898 CBLO 762 USE OF PERMIT Qa`.�k"t'FC.A8,At3i�CSN'; ai1�1; iiQOx;:ai3P � rN�� 1d WATION 2,000..,00 T PEW= F.K.Eff9hMARY PLLIMBINO F'VP, 8EWER 101.000419-000 $30.00 Ilo JAN 2 i 2003 CITY OF LA QUINTA LE33 PR:9nPAM 1911`1 ". WAL PERM IfEF.6 DM NOW RECEIPT DATE BY �f ID FINALE D C'� I INSPECTSjX, 2.,ifit0.0 3 $30,00 5030.: INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck s Exhaust Fans O.K. to Wrap F.A.U. Framing I Compressor Insulation i Vents Fireplace P.L. ; Grills Fireplace T.O. # Fans & Controls Party Wall Insulation ; Condensate Lines Party Wall Firewall i Exterior Lath Drywall - Int. Lath i Final Final BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings j Main Drain Bond Beam Approval to Cover Equipment Location j Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test j Electric Final Waste Lines Heater Final Water Piping Plumbing Final Primbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sevi�LJ.ateral Pool Cover Sewer Connection s Encapsulation Gas Piping > Gas Test Appliances Final Utility Notice (Gas) ,p ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) Final COMMENTS: •— - [-+--QST _—�•a-•,,• ..•++�•r-m^....--r.:rT�—�,., _,.. _ _....•..r.-•,�;•�-,--�,r;-^-s'r.-r,--•.-+rte- ,,-,-.•r.-- ,: --- ys COACHELLA VALLEY WATER DISTRICT * ; i t�, CASH RECEIPT DETAIL NO, '933$'2 Received FDate: rom: ` 1 'i': .. l `` 4 i " �, , t 1. .. i •' /6, ly, a - _ Address:. -•%' . �: � , � s., '•F� •-r �' _ ' : �. ; . =i -t , �f.._ '< <_ �,: `�._..� 11 c Account No: �t% d�� "# ,,� K ., .LJ -�— Lo --� `� `!-� "'6 Tract ( t Service Address 11 �' G.A. Code O Meters) $ • ❑ Servica(s) .0 Backfiow(a) - `� T: ❑ House Latera)(s) 3�a ❑ DelectorCheck(s)- "' .❑ Meter Surcharge' Sanitation Capacity Charge - •� `^, � : r' O W.S.B.F.C. (JTemporary Construction Meter ` ❑ Turn on Charge 4w _ 0 Uncollected Account -Name ❑ inspection Fee -'Tract - - ~' Fee- - ❑ Plan Check Fees Water I Sewer - Tract - O Bond Payment - A.D. - :Bond Assmt. O Customer Deposit ❑ Other . t `- (� r ` TOTAL Remarks: :+. �• . •�; t_�`� d Copy to: 9 .1 Cash Water3ervlce Check _ �) t--^`' :3 �' ,!— ••i' ';. Order �.'. Cashier ._i..;T• CVwt)-4391t1Je9) a 02r'OSe*©2 12:v1pm P. 001'1 u RECEIVED 't ! FEB 0 3 2003 PU13LIC WORKS HAMMER PUMPING INC. JOB INVOICE P.O. Box 2448 CATHEDRAL CITY, CALIFORNIA 92235,-2448 f7601360-7448 "CUSTOMER*!; ORDER NO. j760j 321-7448 t • i 01?I1F.11 -AKFN BY .. UII_'.. TO _ - • ------ - DAI E0RCF.Rr,p DAPI PROMISED 1.1 A. M. I. I P.M. PIJONIE AQ 1.1 RF ' .......... IA MECRAIJIC C. HELP[R' JOB NAME .AND LOCATION / {� —7� — Il DAY wnRt< OE3Cm1'-rION OF lNORI(. C / rye/ fl EXTRFl ,(i•' ° _,7` ®� � 2�I'"f `�- 'ate ! L_`-_'G�� y _PRICE QUANT. —� DESCRIPTION OF MATERIAL. USED— AMOUNT � Gallons , it 14 - PumpingFeeper 1000 gal. �[} n Y470C POurnping Fee peri 000 gal. tI , Out of Area Fee Locating / Opening Fee (per 11000, , Size System: — SIA SERVICE CHARGE OF $20 WILL BE DUE ON ALL RETURNED CHECKS. ------= _ 18% PER YEAR WILL BE CHARGED ON _ !I PAST DUE -ACCOUNTS OVER 30 DAYS. — IIOIJR� LABOR AMOJNT" — —` CIIANIC$ @ — HELPERS —Lj — I herehy Actnnvdedge the salisfav;tury----7-OTAI_ I_/�3(�R --- completion nl LI above. dn;r.riberl .+ork: _ —._— JIGNATURE DATE COMPL.r.TEr] ::i- i./ d/ �i t l''P S �►%C �� ---- TOTAL MATERIALS -- TOTAL LABOR - -- - TAX -- — TOTAL 0E -- FEE -3-2103 MON •10:29 TEL: r` NAME: , i .sem If I} it It it 14 -